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"The Nature of Suicide Bereavement" is based on Responding to Grief, Trauma, and Distress After a Suicide: U.S. National Guidelines (2015), by the Survivors of Suicide Loss Task Force (bit.ly/sosl-taskforce) of the National Action Alliance for Suicide Prevention. The original document is available free for download at bit.ly/respondingsuicide.

The Nature of Suicide Bereavement Special report❋ by Franklin Cook, Unified Community Solutions It is intuitively obvious—and clinically confirmed—that for at least some individuals, the suicide of someone they know has a significant and deleterious effect on their functioning. Nonetheless, while there has been and continues to be debate among academics, researchers, and clinicians about whether and in what ways bereavement after suicide is different from bereavement after other forms of loss (Jordan & McIntosh, 2011b), the personal narratives of countless loss survivors make it clear that, for them at least, suicide has had a transformative effect on their lives (Rappaport, 2009; Stimming & Stimming, 1999; Treadway, 1996). It appears that there are some aspects of bereavement after suicide that share elements with other forms of loss, particularly other traumatic deaths such as homicide (Currier, Holland, & Neimeyer, 2006; Murphy, Johnson, & Lohan, 2003; Murphy, Johnson, Wu, Fan, & Lohan, 2003; Vessier-Batchen, 2007). Nonetheless, it is reasonable to assert that there are aspects of suicide bereavement that are either characteristic of only suicide, or that are likely to be more prominent as a result of suicide than from other causes of death. Importantly, any formulation about the impact of suicide in the end generates empirical questions that, if answered, could lead to targeted responses that would greatly relieve the suffering of people exposed to suicide.

Suicide Is Distinctive

First, suicide bereavement is unique because suicide itself is a singular manner of death. This is a vital but overlooked perspective, which opens the door to asking not only “What makes grief after suicide different?” but also “How does the distinctive nature of suicide itself affect the bereavement experience of survivors?” Logically, there are several aspects of death by suicide that seem likely to influence the experience of suicide loss survivors.

Suicide creates ambiguity about the volition of the deceased. Depending on the circumstances leading to the death, suicidal volition can be understood as existing along a continuum from a “clear and free choice” (someone with a terminal illness who chooses physician assisted suicide) to “not a choice at all” (someone with schizophrenia who hears command hallucinations telling

❋ The source document for this report is Responding to Grief, Trauma, and Distress After a Suicide: U.S. National Guidelines, by the Survivors of Suicide Loss Task Force of the National Action Alliance for Suicide Prevention. The use of the Action Alliance logo is intended to credit the SOSL TF as the author of the source document, but it does not imply endorsement of this report by the Action Alliance.

April 26, 2015

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them to “kill the demon in you”). Various people commonly take different viewpoints about the role of volition in any particular suicide. Some might believe that the thinking of the deceased has to have been severely impaired and death could not have been a rational choice (Wrobleski, 1999). It has been said, for instance, that a person dying of suicide dies against his or her will, as does the victim of physical illness or accident (Rolheiser, 1998). However, to even meet the definition of suicide, the deceased must have taken purposeful action to cause their own death (Andriessen, 2006). Ultimately, what is crucial to the experience of grief is the loss survivor’s perception of the degree of choice in the death, a matter that is often analyzed in excruciating detail by the bereaved. For suicide loss survivors, their belief about the deceased’s volition often becomes a central feature of their grief—and can have a profound impact on the meaning they attribute to the death (Sands, 2009; Sands, Jordan, & Neimeyer, 2011). On one hand, for example, when the behavior of the deceased is perceived as a choice by the survivor, it may lead to struggles with powerful feelings of rejection, abandonment, or anger. On the other hand, when a survivor believes the deceased had no choice (e.g., because of severe depression), then he or she may be comforted by the idea that his or her loved one died of an illness.

Suicide is characterized as preventable in the population. Of course, broadly communicating the idea that suicide is preventable is essential to the public health approach to reducing suicide. However, this message can also contribute to the perception that if suicide in general is preventable, then every suicide is preventable, and therefore, “my loved one’s suicide could have—and should have—been prevented.” This perception (whether it is from the loss survivor’s or from another’s perspective) can add greatly to the suffering of the suicide bereaved. As with the issue of choice, the preventability of individual suicides exists along a continuum (from not at all to unquestionably preventable). A survivor’s view of whether the suicide was preventable or not—at any point during the deceased person’s life—can propel their grief experience in one direction or another. If a suicide is seen as being clearly preventable, then the bereaved may blame others or themselves; feel guilty or ashamed about their “role” in the death; or experience intense anger at others, at themselves, or at God. If, however, a suicide is seen as not at all preventable, survivors may have any number of reactions, ranging from relief (that the deceased’s pain has ended) to despair and helplessness (because nothing could have been done).

Suicide is stigmatized. The stigma historically associated with suicide in most Western societies comes from the belief that suicide is criminal or sinful, a sign of character weakness or the result of evil forces in possession of the individual (Colt, 2006). By extension, the family of someone who dies by suicide has also been viewed as tainted or culpable, and therefore, deserving of being shunned or punished. In contemporary times, there is probably less outright condemnation of suicide, but harsh, institutionalized judgments from the past have left a lingering discomfort for many people regarding how to respond in a supportive way to the suicide bereaved. Although societal views are changing, suicide stigma continues to be a powerful and active force in interactions between loss survivors and their communities (Cvinar, 2005). Research suggests, in fact, that stigma

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negatively affects the tendency of people bereaved by suicide to seek help, the strength of their social connections, and their sense of isolation (Armour, 2006; Feigelman, Gorman, & Jordan, 2009; Feigelman, Jordan, McIntosh, & Feigelman, 2012; Sveen & Walby, 2008). When stigma contributes to a lack of support or sympathy—or to unkindness or even cruelty from other people—it can contribute to secondary wounds that may have a profound impact on loss survivors.

Suicide is traumatic. Death by traumatic means is not uncommon, including homicide, accidental injury, medical emergency, war, terrorism, and natural disaster. Suicide is arguably an inherently traumatizing way to die because its victims must develop and put into motion an immense psychological force in order to accomplish the task of destroying themselves. The magnitude and intensity of this self-destructive energy must overcome the biological drive for self-preservation (Joiner, Van Orden, Witte, & Rudd, 2009). Even if this occurs in small steps, incrementally over time; even if it appears to be a passive act of giving up on life; even if a disorder such as depression is fueling the person’s demise; even if the lethal action taken involves only “going to sleep”—the process of negating one’s life in this way can be construed as an act of violence against the self. When the death of a loved one involves trauma, there is a chance that whatever violence befalls the deceased will traumatize the bereaved.

Survivors of suicide loss potentially are affected by three sources of trauma:

• Psychological trauma: The bereaved might reconstruct and brood over the psychological pain the deceased experienced and over the psychological force that was required for the deceased to kill himself or herself.

• Direct exposure: They might have witnessed the suicide, discovered the body, or been exposed to the death scene or to artifacts from the aftermath, such as personal belongings, an autopsy report, etc.

• Imagined exposure: Even when the survivor is not a direct eyewitness to the death, many survivors create—and some are captivated by—a mental image of what the dying process was like and what the deceased suffered as he or she died.

All that has been described above as unique aspects of dying by suicide may come into play in other modes of death or trauma. It seems clear, however, that there are qualities related to the volition, preventability, stigma, and trauma of suicide that generate in the bereaved particular kinds of emotional reactions or certain patterns of reflection or mental struggle. Therefore, these forces at work in a death by suicide are likely going to color the bereavement experience that follows in its wake.

Aspects of Grief Accentuated by Suicide

In addition to these more or less distinctive aspects of suicide, many other grief responses that are often more pronounced or intense after suicide have been identified (Jordan, 2008, 2009; Jordan & McIntosh, 2011a). Noting that these themes can be present in grief after other kinds of death, Jordan and McIntosh (2011b) point out that suicide bereavement is most different from

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grief after a natural death; somewhat different from grief after a sudden, unexpected death; and most similar to grief after a traumatic or violent death, such as homicide (p. 36, emphasis added). In delineating the common themes after a suicide, Jordan and McIntosh also strongly emphasize that “many (but not all) people bereaved by suicide will manifest many (but not all) of these themes, reactions, and features” (p. 30). Below is a discussion of each of the themes.

Shock. Suicide is often (although not always) sudden and unexpected. Loss survivors often experience it as unfamiliar and unnatural—as being fundamentally wrong in one way (bad or punishing) or another (out of the natural order, unacceptable). As mentioned, the violence associated with suicide can be overwhelming, and its personal impact on survivors can be similar to that of any abrupt event, such as a natural disaster or accidental death. Suicide is often the concluding event of an ongoing crisis for the deceased and, simultaneously, the initiation of an altogether new crisis for the bereaved.

Disbelief. A common reaction to any sudden death is “I can’t believe it,” for it is difficult to grasp and absorb such a profound and not-planned-for occurrence. With suicide, there is often strong disbelief. It seems impossible to some loss survivors that a person they knew intimately could have been thinking of ending their life without the survivor being aware of it. It violates the assumptive world or belief system that the bereaved had about their loved one, themselves, and the world as they knew it. In addition, there can be denial that the death was by means of suicide, which is often relatively short-lived but for some, may endure for a lifetime.

Asking “Why?” Death by any means often compels the bereaved to consider the deepest existential questions about life, death, and why certain things transpire. With suicide, the search for the answer(s) as to why their loved one died is central to the experience of many loss survivors. The complexity, troubling nature, and frequent absence of the answer(s) can be a heavy burden for the suicide bereaved. It is not unusual for loss survivors to feel compelled to conduct their own personal inquest or psychological autopsy into the death, focusing on learning as much as possible about what led to the death; the mental state of the deceased; and when, where, and how their loved one died. The bereaved might also be preoccupied with discovering who knew what, who saw what, who did what, etc. Finding answers, and/or accepting the elusiveness of those answers, is commonly a difficult but necessary part of the journey for the bereaved by suicide.

Shame. References to stigma elsewhere in this essay help to explain the feelings of shame that befall many loss survivors. They may struggle with the moral standing of their deceased loved one, or of themselves (good vs. bad). This can include constructions about the deceased’s eligibility for redemption (heaven vs. hell, forgivable vs. unforgivable), character (strong vs. weak, selfish vs. generous, cowardly vs. courageous), normality (“crazy” vs. sane), and value (significant life vs. wasted life). Shame also can be exacerbated by other themes, especially feelings of self-blame, guilt, and perceived abandonment by the deceased. Police, fire, military personnel and others who place a high distinction on the way a person dies in service can

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be affected by real and/or perceived stigma related to suicide. A death by suicide may be seen as negating all other characteristics of the deceased, even noble or honorable ones.

Blame. It is common for the bereaved to assign responsibility for their loved one’s death to a particular person, event, or circumstance. They might ask, “Is my loved one responsible?” “Am I responsible?” “Is God responsible?” Assigning responsibility can also be driven by the loss survivor’s need to make sense of the incomprehensible. Blaming can be understood as a means of restoring a sense of order in the world—and of protecting the self from feelings of self-blame.

Guilt. People bereaved by any kind of death might feel guilty about what they believe they should, would, or could have done or not done to prevent the death. The answer many survivors of suicide loss arrive at when they ask “Am I responsible?” is “Yes.” People naturally believe in the power of their love and caring to protect their loved ones. In the case of suicide, it is not unusual for people to believe that this power “should” have been able to save their loved one’s life. And in hindsight, they may be able to see actions that could have been taken (or avoided) that might have made a difference. This can contribute to a powerful kind of “magical” or counter-factual thinking about the preventability of the death that can haunt loss survivors for a very long time. There are also instances where a survivor points to a single—and even factual—event that preceded the suicide (“We had a fight”; “I left him alone”) and insists on a simple causal connection between that event and the suicide, even though suicide is multi-causal—involving numerous interrelated contributing factors—and in its essence is a very complex and enigmatic human behavior.

Abandonment and rejection. It is common for bereaved people to feel “left all alone” when someone dies of any cause. Suicide is sometimes seen as the most powerful form of abandonment or rejection possible, because from the point of view of the bereaved, the deceased “chose” death over continuing to live in relationship with the survivor (see the section on volition, above). The suicide bereaved may also feel that the deceased avoided the opportunity to reach out to them or rejected help that was offered. These feelings of abandonment can, in turn, lead to strong feelings of anger at the self (i.e., guilt) or anger at the deceased.

Anger. Anger is often caused by feelings of guilt, blame, abandonment, and preventability. The Latin root of the word suicide means “self-murder,” and in some ways, the reactions of suicide loss survivors can resemble the reactions of homicide survivors, who are often enraged with the perpetrator of the murder. The profound conundrum with suicide is that the “perpetrator” and the “victim” are one and the same person. This can make for a very conflicting and confusing set of emotions for the bereaved, which are not easily resolved. Another link between anger and suicide is that the survivor might feel angry about “secondary losses,” such as being left to raise children without a spouse, facing financial difficulties, or living unaccompanied through retirement.

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Fear. Besides the fears that accompany all kinds of deaths—such as fear of being alone or of financial insecurity—the bereaved by suicide often fear that they or another family member or friend will also die by suicide. The conviction that suicide could happen to anyone, or that suicide “can come out of the blue,” can leave loss survivors wary and hypervigilant over the safety of other loved ones. Fear and hypervigilance can be particularly troublesome for clinicians who have lost a client to suicide.

Increased risk of suicide. In their seminal book on suicide bereavement and caring for loss survivors, Jordan and McIntosh (2011c) conclude:

Compelling evidence now shows that exposure to suicide carries with it the risk for a number of adverse sequelae. Perhaps the most disturbing of these risks is the elevated likelihood for suicide in a person exposed to the suicide of another individual (p.11).

This creates a challenge in supporting loss survivors, for it is surprisingly common for the suicide bereaved to express the wish to die in order to escape the pain of their loss or to join their loved one in an afterlife. It is vital, therefore, to determine whether anyone speaking of dying or of killing themselves is at risk for suicide, including ensuring the person’s safety and, if necessary, making a prompt and effective referral of the person to a competent mental health professional for a thorough clinical assessment.

Relief. Suicide sometimes marks the end of a long and grueling period in which a family is constantly in turmoil over a person’s mental illness, substance abuse, and/or other stressful, painful, or even unmanageable situation. They may have been on a prolonged “suicide watch” with the deceased. Or, as a result of a psychiatric disorder or other condition, the deceased may have been difficult, exhausting, or abusive to live with. Or it may simply have been very distressing to watch the loved one struggle with his or her emotional and life problems. In such instances, it is natural for loss survivors to feel relief that the ordeal is over. However, this feeling can be troublesome, contradictory, and confusing, because it is judged by others and/or by the survivor himself or herself to be unacceptable to experience relief that someone has died. The bereaved also may feel reluctant or ashamed to share their feeling of relief with others—and misunderstood if they do disclose such emotions.

Finally, there are several modes of suicide that likely affect those exposed to a fatality in particular ways, but about which there is little research on the effects. Among these are murder-suicide (a suicide following a homicide), double suicide or suicide pacts (suicides that are directly and purposefully related to each other), and ambiguous death (the manner of death cannot be definitively established).

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